Failure to Revise Care Plan for Inappropriate Sexual Behavior
Penalty
Summary
A deficiency was identified when the facility failed to revise a resident's care plan to address inappropriate sexual behavior, despite documented incidents. The facility's policy requires that care plans be revised as changes in a resident's condition dictate and reviewed at least quarterly. However, clinical record review for a resident admitted with depression, anxiety, hyperlipidemia, and acute kidney failure showed multiple nursing notes documenting the resident making sexual comments and inappropriate remarks toward staff, as well as displaying anxiety and frequent call bell use when staff did not respond as desired. Despite these documented behaviors, the resident's current care plan did not include any interventions or plans to address the inappropriate sexual behavior. This omission was confirmed by the Director of Nursing. The lack of care plan revision occurred even though the facility's own policy and federal regulations require care plans to be updated to reflect changes in resident behavior and needs.
Plan Of Correction
All residents with currently documented behaviors and those on psychotropic medication will be audited to ensure care plans are accurate. Staff will be educated on updating care plans to reflect residents' needs. Care plan policy has been updated. The DON or designee will conduct audits weekly for 4 weeks, then perform random audits monthly for 3 months of care plans for residents with behaviors or on psychotropic medication to ensure accuracy. Care plans will also be reviewed and updated with each MDS to reflect the current needs of each resident.